Robert Roos 
News Editor
News Editor
May 17, 2013 (CIDRAP News) – The World Health Organization (WHO)
voiced increased concern today about the possibility of community
transmission of the novel coronavirus, while sketching in a few more
details about a hospital-centered case cluster in Saudi Arabia and the
clinical spectrum of the infection.
Although sustained transmission in the community has not been
seen, the WHO said, "The continued appearance of cases that are not part
of larger clusters, and who do not have a history of animal contact,
increases concerns about possible community transmission. This
possibility is being investigated by authorities in Saudi Arabia."
The WHO has confirmed 40 cases and 20 deaths from novel
coronavirus infections since the pathogen was identified in 2012, most
of them in older men.
The virus has gone by various names to date, but a committee of
experts recommended this week that it be called Middle East respiratory
syndrome coronavirus, or MERS-CoV. (CIDRAP News will use the new name
henceforward.)
Today's WHO summary and literature update follows the emergence in
the past 2 weeks of the hospital cluster in Saudi Arabia and the first
two MERS-CoV cases in France.
The hospital cluster has been reported to include 21 cases, with 9
deaths; news reports have linked it to the Al-Moosa General Hospital in
Hofuf, Eastern province. On May 15 the WHO reported that two healthcare
workers who caught the virus from patients were part of the cluster.
Today's report adds some new information about the cluster but
also raises more questions. It says the cluster includes 16 males and 5
females, with a median age of 56 years. Six patients remain critically
ill, implying that another six have less severe illness or have
recovered.
Most of the cases were linked to one healthcare facility in
Al-Ahsa, but, as reported previously, some of those who became infected
were not patients at the facility, the report notes.
It adds, "Three family members of cases linked to the facility and
two health care workers not associated with the Al-Ahsa facility but
who had contact with laboratory confirmed cases have become infected."
The report doesn't specify where the two healthcare workers were
exposed to infected patients. WHO spokesman Gregory Hartl told CIDRAP
News today that the agency doesn't know where the exposures occurred.
The report goes on to say, "Two additional cases have been
identified in the community that did not have any links with other cases
from the Al-Ahsa healthcare facility. Although investigations are still
ongoing into the source of this outbreak, early information indicated
that only a small minority of these cases had contact with animals in
the time leading up to their illness."
The WHO reiterated previous statements that MERS-CoV is believed
to be of animal origin and to be sporadically spread to humans by an
unknown route. Human transmission so far has been confined to healthcare
facilities and close contacts of patients, the report noted.
It adds, "The recent increase in cases may in part be related to
increased awareness among the medical community, however the
demonstrated ability of this virus to transmit between humans and to
cause large outbreaks, has increased concerns about the possibility of
sustained transmission."
On the clinical manifestations of MERS CoV infection, the
statement revealed that many patients have had gastrointestinal
symptoms, including diarrhea. "One patient, who was immunocompromised,
presented with fever, diarrhea and abdominal pain, but had no
respiratory symptoms initially; pneumonia was identified incidentally on
a radiograph," it states.
That description apparently refers to the first French
case-patient. In reporting that case on May 8, the WHO said the patient
was immunocompromised and did not have respiratory symptoms when he
first got sick on Apr 23. Other reports said the patient, a 65-year-old
man, fell ill after returning from a 9-day vacation in Dubai, United
Arab Emirates.
Other clinical findings in MERS-CoV cases include acute
respiratory distress syndrome, renal failure requiring hemodialysis,
consumptive coagulopathy, and pericarditis, the WHO said.
In other comments, the WHO said that the large number of patients
with preexisting medical conditions "suggests that increased
susceptibility from underlying medical conditions may play a role in
transmission."
The agency also said the healthcare workers' cases and other
instances of nosocomial transmission point up the need for careful use
of infection control measures.
Like the WHO statement, an updated MERS-CoV risk assessment
released today by the European Centre for Disease Prevention and Control
(ECDC) observed that infected persons may not have respiratory symptoms
at first.
"The first French case raises the possibility that presentations
may not include respiratory symptoms initially, especially in those with
immunosuppression or underlying chronic conditions," the assessment
says. "This needs also to be taken into account when revising
case-finding strategies."
The ECDC also said that mapping routes of medical evacuation or
emergency care from the Arabian Peninsula and countries neighboring the
European Union should be considered to determine the most vulnerable EU
centers where cases might arrive.
Regarding the MERS-CoV situation in the Middle East, the agency
said, "It is unusual to have such a degree of uncertainty at this stage
in an outbreak."
See also:
May 17 WHO summary and literature update
May 17 ECDC risk assessment
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